[Dysphagia] Chin tuck etc

[NBurnett at cmh.org (Nancy Burnett)]

Thank you so much for your wonderful comments Suzanne and for sharing such down-to-earth examples of activities! 
One question - is the amount of chin tuck used "when tipped slightly down...as if...nodding slightly when saying 'yes'" the same degree of chin tuck used as a strategy? I always thought the strategic chin tuck was more pronounced. 

Nancy Burnett,
Speech-Language Pathologist,
Cambridge Memorial Hospital,
700 Coronation Blvd.,
Cambridge, Ontario.
N1R 3G2
Telephone: 519 - 621 -  2330 ext 1126/Pager 1104
Fax: 519 - 740 - 4978  Attention Nancy Burnett 3BN
Email: nburnett at cmh.org


	-----Original Message-----
	From:	dysphagia-bounces at b9.com [SMTP:dysphagia-bounces at b9.com] On Behalf Of Suzanne Morris
	Sent:	November 28, 2006 3:06 PM
	To:	dysphagia at b9.com; mbuckie at dmc.org
	Subject:	Re: [Dysphagia] Chin tuck etc

	The practicality of encouraging a "chin tuck" to improve swallowing  
	skills has interested me since I first began working with children  
	with feeding and swallowing difficulties.   I'd like to add a common- 
	sense perspective to the debate.   In recent years therapists and  
	researchers have tried to justify encouraging a chin tuck in patients  
	because of debatable anatomical reasons and as ways to prevent  
	aspiration and pneumonia. The argument is made that there is no clear  
	research that shows that swallowing is improved or aspiration is  
	reduced when the chin tuck is used.  When I was introduced to the  
	strategy back in the early 60s the reason cited was to increase the  
	overall efficiency with which the oral-pharyngeal mechanism could  
	function.  When the head is tipped back, even slightly, there is a  
	slight drag on the larynx and hyoid.  As the head goes further back  
	into capital extension, the tongue and lips/cheeks also tend to pull  
	back as the muscles are placed at a greater disadvantage.    This is  
	related to the mechanical relationship of the different body parts.  
	it's not that we can't suck and swallow with the head in  
	hyperextension.  We can, but it takes more muscle effort to  
	compensate for the need to counteract the backward pull of the  
	muscles and structure.  If a client has a neurological problem that  
	increases the strength of reflexive extensor patterns, there may also  
	be an increase in muscle tone that makes swallowing efficiently even  
	more of a challenge.

	There are several personal explorations that i use when I am teaching  
	parents or workshop groups.  These activities allow others to  
	appreciate subtle differences and build greater awareness of the  
	swallowing mechanism.  1) Begin with the head and neck in good upward  
	alignment with the back of the neck straight and the chin tipped  
	slightly down toward the chest (i.e. a chin tuck) as if the head were  
	nodding slightly when saying "yes".  Drink water with the head in  
	this position and simply notice the feeling of the muscles and the  
	overall coordination and speed of the jaw, tongue, lips/cheeks and  
	the larynx/hyoid.   Secondly, drink the water as you very slowly tip  
	the chin up toward the ceiling.  Notice the point where there is a  
	very slight change in the feeling of these same muscles and muscle  
	groups.  Continue tipping the chin upward as far as possible;   
	finally bend the neck back into full hyperextension while drinking.    
	As a third exploration, begin with the head in full hyperextension  
	and very slowly bring it forward into the well-aligned head and neck  
	position with the chin tuck.   It is very easy for most people to  
	experience the difference and the way in which they make certain  
	internal adjustments to be able to continue drinking safely.   2) A  
	second experiment is to explore the same basic head and neck  
	alignment activity while repeating the syllable sequence of / 
	mamamamama/.  In this activity you experience more of the impact on  
	the jaw and the lips (as they are connected to the jaw).  This is a  
	great activity to do in a group.   Get everyone to repeat the / 
	mamama/ sequence as fast as they can and keep it going as long as  
	they can with the head in good chin tuck alignment.   Then have them  
	do it as the chin begins to point up toward the ceiling.   In the  
	first exploration the syllables are very fast and well sustained.    
	However, in the second exploration as the chin tips upward, the jaw  
	is more biased toward opening and there is a very slight pull-back of  
	the lips.  The whole group suddenly begins to slow down in their  
	syllable repetition.  It can lead to a very dramatic awareness of how  
	head position is related to the efficiency of the oral mechanism.

	Many years ago I was invited to present a workshop that was held in  
	one of the old traditional medical school amphitheaters.  The rows of  
	seats were very steep and it was a challenge to maintain eye contact  
	with the whole group.  When I teach I rely heavily on eye contact  
	with the group to create an interactive connection and also to be  
	aware of group non-verbal feedback that allows me to make slight  
	modifications in how I teach.  I have learned to pace myself in  
	teaching so that my voice never gets tired or strained even when  
	speaking continuously for 3-4 days in a row.   However, during this  
	particular workshop, I developed a slight laryngitis by the end of  
	the first day and I was very tired.   I knew I wasn't coming down  
	with a cold, which could have accounted for the vocal strain.   I  
	realized that I had spent the entire day teaching with my chin tipped  
	up and my head in slight hyperextension in order to use eye contact  
	with those in the upper rows.   So the next day, I very consciously,  
	kept my head in good chin tuck alignment and dissociated my upward  
	eye gaze from my head and neck position.   I had no problems with my  
	voice for the last 2 days of the workshop.  It was amazing to me to  
	see how a very small tip-back of my head could place my larynx at  
	enough of a disadvantage that vocal strain developed.

	So my common sense question is: do we really need to create fancy  
	explanations for a chin tuck technique in relationship to pneumonia  
	or other conditions that have many many coexisting variables?   Could  
	we simply talk about how the body just functions more efficiently  
	when its parts are in alignment and don't have to work so hard?  This  
	is a concept that is very familiar to anyone who appreciates sports,  
	dance or other activities involving physical coordination.   It is so  
	easy to demonstrate how this works for nurses and care providers, who  
	once they understand the principle in their own body are more likely  
	to implement the strategy with others.
	__________________________________
	Suzanne Evans Morris, Ph.D.
	Speech-Language Pathologist
	New Visions
	1124 Roberts Mountain Rd.
	Faber, VA 22938
	(434) 361-2285 ext. 5
	www.new-vis.com


	>
	> mbuckie at dmc.org wrote:
	>
	>   I haven't looked at this study in depth, but I have long seen the  
	> chin
	>   tuck as the "magic bullet" by nurses, therapists and the summary  
	> that
	>   was posted said patients who use chin tuck still got pneumonia. I  
	> wasn't
	>   aware that was the purpose of the chin tuck..that's a pretty big  
	> leap to
	>   make.
	>   *** That has been the response I have always received when I  
	> asked about the reason for its use due to the belief that  
	> aspiration inevitably leads to pneumonia and "chin tuck prevents  
	> aspiration". That, I submit, is the "big leap."

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